Prevalence and Correlates of HIV Risk Behaviors of Inmates in a State Prison System

Prevalence and Correlates of HIV Risk Behaviors of Inmates in a State Prison System Titilayo Abiona, MD, FMCPH HIV/AIDS Research and Policy Institute College Retreat 2008

Background • Higher HIV/AIDS rates among inmates vs. general population • HIV prevalence between 4 & 10x higher among inmates than in the general population • Inmates engage in risk behaviors before, during & after incarceration • What is the exact mechanism linking incarceration with HIV infection? College Retreat 2008

Conceptual Model College Retreat 2008

Overall Aim of the HIV/Incarceration Study • Examine the plausible links between incarceration and HIV infection College Retreat 2008

Specific Objectives • Describe pre-incarceration risk behaviors of inmates • Identify and quantify the prevalence of risk behaviors during incarceration • Determine the sociodemographic correlates of risk behaviors during incarceration College Retreat 2008

Methods • Study Location • Illinois Correctional Facilities • Study Design • Cross-Sectional Descriptive • Study Population • Male and female inmates • 18 years of age or older • Continuously incarcerated for at least six months • Able to speak and write English College Retreat 2008

Methods • Sample Size Determination • Computer Programs for Epidemiologists (PEPI) version 4.0 • based on • estimate of condom use rate among adults in the US =36% • 95% CI • maximum acceptable difference from true proportion = 3% • A minimum sample size of 1025 was calculated • Over-sampling done to adjust for non-participation • 2,000 inmates finally selected College Retreat 2008

Methods • Sampling Technique • Multi-stage sampling technique • 1st stage, correctional facilities in Illinois stratified by level of security into maximum, medium, and minimum • 2nd stage, 17 facilities randomly selected. 15 male, 2 female. • 3rd stage, random selection of participants from current inmate lists provided by the Illinois Department of Corrections (IDOC) • Actual number of inmates selected from each prison depended on the overall number of inmates in the prison College Retreat 2008

Methods • Data Collection Method • Questionnaire • Questionnaire • Structured • Sections: • Demographic information • Incarceration history • Lifetime behaviors and within 6 months before incarceration • Sexual Behavior, Injection Drug use, Needle Sharing, Tattooing, Body Piercing • Behaviors during incarceration • Sexual Behavior, Injection Drug use, Needle Sharing, Tattooing, Body Piercing College Retreat 2008

Methods • Questionnaire cont’d • Items written in simple English = 6th grade reading level. • Test-retest reliability of questions established with the Pearson’s product moment correlation coefficient, r • 0.71 (p=0.001) - drug use • 0.78 (p <0.001) - tattooing • 0.79 (p=0.03) - body piercing • 0.74 for questions - sexual behavior • Cronbach’s alpha (KR-20) for internal consistency = 0.0803 College Retreat 2008

Methods • Data Analysis • Statistical Package for Social Sciences (SPSS) 15 • Frequencies and percentages of demographic data and HIV risk behaviors • Multivariate logistic regression analysis to assess predictors of having sexual intercourse in prison. • Significant variables in the unadjusted analysis entered into multivariate logistic regression model • Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated • p-value < 0.05 accepted for statistical significance College Retreat 2008

Methods • Ethical Considerations • Approved by the CSU Institutional Review Board (IRB) • Confidentiality ensured by: • No personal identifying information on questionnaire • Facilities identified using codes • Survey information not shared with prison staff, law enforcement or court systems • Questionnaires locked in a file cabinet at the Institute and will be destroyed after five years • Only the Principal Investigators and authorized study personnel had access to the data College Retreat 2008

Results and Discussion • 1,819 participants: 1, 293 (71.1%)men and 526 (28.9%) women completed the survey • Response rate = 91% • Overall average response rate to survey questions = 96% • Number of participants that responded to each question varied College Retreat 2008

Table 1: Sociodemographic Characteristics of Participants College Retreat 2008

Table 1: Sociodemographic Characteristics of Participants Cont’d College Retreat 2008

Table 2: Pre-Incarceration Risk Behaviors College Retreat 2008

Figure 1: % of Respondents reporting Multiple Vaginal Sexual Partners in the 6 Months before Arrest (n= 1762) Percentage College Retreat 2008

Figure 2: % of Respondents reporting Multiple Anal Sexual Partners in the 6 Months before Arrest (n= 1762) Percentage College Retreat 2008

Figure 3: % of Respondents who never/rarely used Condoms in the 6 Months before Arrest College Retreat 2008

Figure 4: % of Respondents who did not use Condoms during last Sexual Intercourse Percentage College Retreat 2008

Figure 5: % of Respondents who had ever Injected Drugs Percentage College Retreat 2008

Figure 6: Injection Drug Use among Ever Users in the Six Months before Arrest Percentage College Retreat 2008

Figure 7: % of Injection Drug Users who had ever Shared Needles Percentage College Retreat 2008

Figure 8: Needle Sharing in the 6 Months before Arrest among Respondents who had ever Shared Needles Percentage College Retreat 2008

Figure 9 % of Respondents who obtained Tattoos and Body Piercing from non-professional artists Percentage College Retreat 2008

Table 3: Risk Behaviors during Incarceration College Retreat 2008

Figure 10: Types of Sexual Intercourse during Incarceration (n=158) Percentage College Retreat 2008

Figure 11: Context of Sexual Intercourse during Incarceration (n=158) College Retreat 2008

Table 4: Characteristics and Behaviors Associated with Sexual Intercourse during Incarceration Bold Figures: p<0.05 College Retreat 2008

Table 4: Characteristics and Behaviors Associated with Sexual Intercourse during Incarceration Cont’d Bold Figures: p<0.05 College Retreat 2008

Conclusions • Inmates engage in risk behaviors before and during incarceration • Length of stay in prison, sexual orientation and receiving a tattoo in prison were associated with risk behaviors in prison • Findings support both the importation and deprivation models of inmate behavior College Retreat 2008

Recommendations • HIV prevention intervention should be commenced as soon as possible after incarceration • Recreational activities should be provided for inmates • Condom use policy in prison needs review College Retreat 2008

Study Limitations • Possible Underreporting- Social Desirability Bias • Use of a self administered questionnaire and Social desirability bias may affect results and generalizability of findings • Non response to questions may be a source of bias • The small numbers of inmates reporting HIV risk behaviors in prison prevented the identification of independent risk factors for some behaviors • Inmates who were selected but refused to participate in the study may differ significantly from those who participated. This may have affected the prevalence of the risk behaviors reported. College Retreat 2008

Future Research • Risk Behaviors of Partners of Inmates • Prospective Study of Risk Behaviors and HIV transmission in Prison College Retreat 2008

Acknowledgements • Illinois General Assembly and the Illinois Department of Public Health- Funding • Dr. Mainza Lukobo-Durrell- contribution to conceptualizing the study • Research assistants –Josie McDonald, Wayne Scott-Williams, Jerry Goldstein and Emmanuel Osunkoya- for their dedication throughout the period of the study • State Representative Constance Howard- co-sponsoring the bill which created the African American HIV/AIDS Response Act and for her personal involvement in establishing the collaboration between the Institute and IDOC • IDOC officials-support in facilitating data collection College Retreat 2008

College Retreat 2008

Prevalence and Correlates of HIV Risk Behaviors of Inmates in a State Prison System